Resi school answers Flashcards
A patent airway is essential to life. What key points need to be considered when assessing the patency of a person’s airway?
Assess the client’s breathing by observing:
a) The work of breathing (recession, respiratory rate, depth, effort including the use of accessory muscle use).
b) The effectiveness of breathing (oxygen saturation, chest expansion, breath sounds).
c) Chest wall movement and any chest injury.
d) Whether the client can talk. Is the client breathless when talking? Are they able to talk in sentences or only single words?
e) If there is any pain being experienced by the client on inspiration or expiration
f) Position of trachea (midline or is deviation noted).
g) Auscultate for bilateral breath sounds including the lung peripheries.
h) That the stomach is not being ventilated and count respiratory rate. A nasogastric tube maybe required to be inserted to treat and prevent gastric dilatation.
i) The effects of inadequate respiration (heart rate, mental state)
Why is important to monitor the vital signs of a person with suspected airway compromise?
An assessment of the vital signs provides essential physiological information about patients. Impending critical illness and respiratory compromise can alter these signs. Monitoring of vital signs will identify deterioration in the person condition.
When would the nurse insert a Guedel’s airway (oropharangeal airway)?
When the spontaneously breathing person is unconscious or unable to maintain the patency of their own airway.
In what circumstances would a LMA be used?
Indicated as an alternative to the face mask for achieving and maintaining control of an airway, and has proved to be a valuable tool in the emergency management of a failed intubation, as it helps establish and maintain an airway
What is the nursing role following endotracheal tube intubation?
The nurse should check that the ET tube is in the correct place. this is done by watching for both equal and bilateral chest movements and listening for air entry. The nurse should secure the ET tube once it is in place to prevent it from moving
. List the nursing responsibilities when caring for a person with a tracheostomy tube insitu?
- It is vital that the cuff pressure is checked regularly and that the cuff is deflated and reinflated at appropriate intervals to prevent the effects of pressure on the internal wall of the trachea. Suction should be applied above the cuff prior to deflation to remove any secretions.
- Pre-oxygenation of person may be needed prior to suctions. • Need to treat suctioning and dressing changes a clean – aspetic procedures – needed to assist in reducing risk of resp infection
What is the purpose of artificial airway suctioning?
To remove secretions from the airways. Tracheostomy suctioning may improve the patency of the airway, oxygenation and gaseous exchange
Unconscious person who is breathing spontaneously with an oxygen saturation of 95% in room air.
Artificial airway needed?
If yes why?
Type of airway needed
Yes
To protect airway Oropharangeal airway.
Oxygen saturation monitoring is essential
. Person with a burn injury to 50% of their body after being trapped in a house fire
Artificial airway needed?
If yes why?
Type of airway needed
Yes
Airway may be compromised. Fluid replacement needed ETT
Oxygen saturation monitoring is essential.
Unconscious 10 year old boy postoperative inguinal hernia repair being cared for in recovery.
Artificial airway needed?
If yes why?
Type of airway needed
Yes
To protect airway Oropharangeal Or Nasal airway plus Hudson mask with 02 at 6/L
Oxygen saturation monitoring is essential
Unconscious person who is breathing shallow with an oxygen saturation of 82% in room air.
Artificial airway needed?
If yes why?
Type of airway needed
Yes
Shallow respirations and low oxygen saturations
Oropharangeal Non-rebreather – 10 to 15/L
Person with a burn injury to their hands as a result of spillage of boiling water.
Artificial airway needed?
If yes why?
Type of airway needed
NO
Unconscious person who is not breathing.
Artificial airway needed?
If yes why?
Type of airway needed
Yes
To protect airway Oropharangeal and bag and mask followed quickly by ETT
Oxygen saturation monitoring is essential
Unconscious person who is breathing spontaneously but has an oxygen saturation of 88%.
Artificial airway needed?
If yes why?
Type of airway needed
Yes
To protect airway Oropharangeal Or Nasal airway plus Hudson mask with oxygen at 6/Lpm
Oxygen saturation monitoring is essential
Oropharyngeal and nasopharyngeal airways
Oropharyngeal and nasopharyngeal airways can be used in-conjunction with bag and mask ventilation. These airways are used in the unconscious person who is unable to maintain their own airway. The nurse is able to insert both the oropharyngeal and nasopharyngeal airways and a Hudson mask can also be applied over these airways to ensure the person is being adequately oxygenated.
Laryngeal Mask Airway (LMA)
Laryngeal Mask Airway (LMA) is a Latex-free, silicone rubber tube connected to an elliptical mask with an inflatable outer rim. To insert an LMA the person’s mouth needs to be opened and the tip of the cuff pressed upward against the palate so the cuff is flattened against it. The LMA is then pushed back along the person’s palate until resistance is felt. Once resistance is felt the mask is situated at the hypopharynx. The cuff of the LMA is then inflated with 2–4 ml air to create a seal.
Endotracheal tube (ETT)
Endotracheal tubes (ETT) are used to maintain the airway of people who are unable to maintain their own patent airway. ET tubes come in a number of sizes, and are measured by the size of their internal diameter. The choice of ETT size is a balance between choosing the largest size to maximise air flow and minimise airway resistance and the smallest size to minimise airway trauma. An ETT is inserted by a skilled practitioner. To insert the EET the larynx is viewed using a laryngoscope. A laryngoscope is a rigid instrument used to examine the larynx and to facilitate intubation of the trachea. The ETT is held in the operator’s dominant hand and is introduced into the right side of the month. The operator should be able to see the tip of the ETT pass in the larynx, between the abducted cords. The ETT is then passed approximately 1 cm through the vocal cords. Important—the cuff of the ETT should not be inflated until it is passed the vocal cords.
Tracheostomy tube
A tracheostomy tube is inserted through the creation of an opening in the trachea (i.e stoma) to enable the maintenance of a person’s airway. The placement of the tracheostomy tube can be either permanent or temporary—depending upon the reason the tracheostomy was needed in the first place. The tracheostomy tube is placed below the vocal cords. As a result air is no longer humidified or filtered. In addition the bypassing of the vocal cords can affect the person’s ability to talk. Tracheostomy tubes can be cuffed or un-cuffed. In people with a cuffed tracheostomy tube there is no passage of air passed the vocal cords and talking is not possible without an aid. In persons with an un-cuffed tracheostomy tube breathing occurs around the tube and the person has the ability to talk. Complications that can occur with a tracheostomy tube insitu include: loss of airway and infection, bleeding or pnuemothorax, aspiration of gastric content (particularly problematic in people with un-cuffed tubes), nerve damage or posterior tracheal wall penetration to name just a few
The primary objectives when caring for people with a tracheostomy insitu include:
• Ensuring there is a spare tracheostomy tube available in case of dislodgement. • Ensuring the tube is secure. This is achieved by ties that are secured around the tube and person’s neck. The nurse may require the assistance of a second person when changing tracheostomy tube ties. • The person needs to be fully informed at all times as to what the nurse is doing in relation to their tracheostomy tube. Understandably the person may become anxious if they feel their airway is being obstructed. • It is essential the nurse maintain standard pre-cautions when performing tracheostomy care. • When changing the ties of the tracheostomy the nurse needs to ensure they have a gloved assistant who is able to hold the tube securely throughout the procedure and that the tube is secure at the end of the procedure. Please note—this is a 2 person procedure. • When dressing the tracheostomy the nurse needs to ensure they have the correct dressing and that the stoma is cleaned thoroughly with normal saline. • It is important for the nurse to document the procedure in the person’s nursing notes.
Outline the body’s compensatory actions for
Respiratory Acidosis
Respiratory Acidosis = in respiratory acidosis the respiratory rate is depressed and is the cause of acidosis therefore renal system tries to compensate for respiratory acid-base imbalance due to respiratory disease.
Outline the body’s compensatory actions for the following imbalances:
Metabolic alkalosis:
Metabolic Alkalosis = shallow breaths blow off CO2 – decrease respiratory rate to retain CO2
Outline the body’s compensatory actions for the following imbalances:
Respiratory alkalosis
Respiratory Alkalosis = kidneys start excreting HCO3 - to compensate for alkalosis.
Outline the body’s compensatory actions for the following imbalances:
Metabolic acidosis
Metabolic acidosis = respiratory system compensates for metabolic acid-base imbalance by increasing resp rate
What are the indications for an intercostal catheter?
Pneumothorax, haemothorax, lung requiring re-expansion
Gravity is usually sufficient to drainXXX AND XXXXX from the pleural space
Gravity is usually sufficient to drainAIR AND FLUID from the pleural space
The connections of the intercostal catheter and drainage bottle should be checked for xxxxx and xxxxxxx
The connections of the intercostal catheter and drainage bottle should be checked for leaks and security
List safety issues relevant to the nursing care of a person with an intercostal catheter
Check connections tights; if water in drainage system keep bottles below level of chest; have normal saline bottle at bed side in case of accidental disconnection – ICC end can be placed in bottle of Normal Saline so no air enters pleural space. RN then has time to replace drainage system if needed; Check dressing for ooze and change as per hospital policy.
Identify the landmarks on the chest, which will assist you in finding the correct position to listen to the heart
- Aortic region (between the 2nd and 3rd intercostal spaces at the right sternal border) (RUSB – right upper sternal border). 2. Pulmonic region (between the 2nd and 3rd intercostal spaces at the left sternal border) (LUSB – left upper sternal border). 3. Tricuspid region (between the 3rd, 4th, 5th, and 6th intercostal spaces at the left sternal border) (LLSB – left lower sternal border). 4. Mitral region (near the apex of the heard between the 5th and 6th intercostal spaces in the mid-clavicular line) (apex of the heart).
After this initial examination in the supine positions, several additional maneuvers should be accomplished in the thorough cardiac exam, as follows:
- Instruct the patient to turn onto their left side (left decubitus position) and listen with the bell of the stethoscope at the apex for mitral stenosis (low pitched diastolic murmur).
- Instruct the patient to sit upright and re-examine the 4 percordial regions, again with the diaphragm of the stethoscope.
- Instruct the patient to lean forward, exhale, and hold their breath. Listen with the diaphragm between the second and third intercostal spaces at the right sternal (aortic) and left sternal (pulmonic) areas for aortic regurgitation.
With reference to the above diagram, briefly explain the significance of:
P Wave: depolarisation of the artia
QRS complex: depolarisation of the ventrciles
T Wave: repolarisation of the ventrciles
P Wave: depolarisation of the artia
QRS complex: depolarisation of the ventrciles
T Wave: repolarisation of the ventrciles
What are the possible consequences of inaccurate chest electrode placement?
Inaccurate ECG reading and as a result in accurate diagnosis of client condition
List your initial actions when a person is not breathing.
Check airway and clear if obstruction found
